Download Antimicrobial Resistance

Antimicrobial Resistance (AMR)
Tjandra Yoga Aditama
1
AMR was foreseen early
Alexander Fleming,
“The time may come when penicillin
Nobel Lecture,
can be bought by anyone in the
December 1945
shops. Then there is the danger that
the ignorant man may easily under
dose himself and by exposing his
microbes to non-lethal quantities of
the drug make them resistant”
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|February 2016
1928 - Sir Alexander Fleming discovered Penicillin - The first of
antibiotics that would prove to be some of the most efficacious lifesaving drugs
In the near future - Due to AMR, we are looking at a world without
antibiotics again
No Antimicrobials - What Would That
Mean?
“If antibiotics stopped working, we would find a substantial
increase in deaths due to infections”
“In a world with few effective antibiotics, modern medical
advances such as surgery, transplants, and chemotherapy
may no longer be viable due to the threat of infection”
~ National Strategy for Combating Antibiotic-Resistant
Bacteria (Sep 2014)
AMR is
already a
substantial
killer ... and is
only
becoming
bigger
What is at stake with AMR?
Safety net shrinking
- Surgery, injuries, cancer, diabetes, malnourishment…..
Increasing AMR deaths today in all age groups
- Europe 25,000 per year
- Thailand 38,0000 per year
- USA > 23,000 deaths per year among
By 2050, possibly 10 million deaths per year, more
than cancer
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Why is AMR a Global Health
Concern?
The rate at which microbes are
acquiring resistance is
GREATER than the rate at
which antimicrobials are being
discovered
What is at stake with AMR?
Worldwide, common
infections becoming
more resistant to
antimicrobials
- Blood, urinary tract,
pneumonia, sexually
transmitted, skin, TB ..
Children, women & men
at higher-risk for severe
illness or death
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| February 2016
Trends in development of new antibiotics
Laxminarayan, Science, 2014
“The infrastructure of antibiotic
discovery both in academia and in
industry is at a dangerously low level
and needs to be rebuilt”
Number of additional deaths per year in the USA under
a 30% decreased efficacy of antibiotic prophylaxis
Teillant et al, Lancet Infect Dis, 2015
Huge overall costs
Estimated yearly US
costs today (by CDC)
- Direct up to $20 billion
- Indirect up to $35
billion
By 2050, one
projection
- Cumulative loss of
2% - 3.5% global GDP
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|February 2016
Treatment costs go up when
1st line antimicrobials can’t
be used
Loss of first line drugs increases drug costs
Source: WHO Policy Perspective 2005, adapted from WHO Model Formulary, WHO Clinical Guidelines and
Management Sciences for Health’s 2004 International Drug Price Indicator Guide (slide courtesy: David Heymann)
Percentage of Staphylococcus aureus isolates that are methicillin resista
country (most recent year, 2011-14)
Source: CDDEP 2015, WHO 2014 and PAHO, forthcoming
Where available, data from hospital-associated MRSA and invasive isolates have been used. In their absence, data from community-associated MRSA or all specimen sources are
included. Only countries that reported data for at least 30 isolates are shown. Depending on the country, resistance to one o r more of the following drugs were used to test for MRSA:
Oxacillin, cefoxitin, flucloxacillin, cloxacillin, dicloxacillin, and methicillin. Intermediate-resistant isolates are included as resistant in some calculations, as in the original data source.
Percentage of extended-spectrum beta-lactamase producing Escherichia
country (most recent year, 2011-2014)
Source: CDDEP 2015, WHO 2014 and PAHO, forthcoming
Where available, data from invasive isolates have been used. In their absence, data from all specimen sources are included. Only countries that reported data for at least 30 isolates are
shown. Depending on the country, resistance to one or more of the following drugs were used: Ceftazidime, ceftriaxone and cefotaxime. Intermediate-resistant isolates are included as
resistant in some calculations, as in the original data source.
*Indicated by third-generation cephalosporin resistance
Percentage of carbapenem-resistant Klebsiella pneumoniae, by countr
recent year, 2011-2014)
Source: CDDEP 2015, WHO 2014 and PAHO, forthcoming
Where available, data from invasive isolates have been used. In their absence, data from all specimen sources are included. Only countries that reported data for at least 30 isolates are
shown. Depending on the country, resistance to one or more of the following drugs were used: imipenem, meropenem, ertapenem and doripenem. Intermediate-resistant isolates are
included as resistant in some calculations, as in the original data source.
2014 WHO issued “Antimicrobial
resistance: global report on surveillance”
Survey of 114 countries in all regions
Selected combinations of hospital & community
bacteria - antibiotic resistance patterns
Limitations
- Surveillance gaps in many countries
- No standard methodology
But best available global picture
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| February 2016
General Findings
Very high rates of resistance to key antibiotics by
common bacteria in all regions
- E coli, K pneumoniae, S aureus, S pneumoniae, N
gonorrhea ….
- 3rd generation cephalosporins, fluoroquinolones,
methicillin …..
Under reporting of major infections like MDR TB
Significant gaps in surveillance & information
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| February 2016
Clonal spread of S. pneumoniae 23F
Finland
France
BM4200
1978 ?
Spain
Cleveland
South Korea
Tennessee
Taiwan
Hong Kong
Philippines
Thailand
Mexico
Colombia
Malaysia
Singapore
Brazil
Chile
Uruguay
Argentina
South Africa
Slide courtesy: Keith Klugman
1
International travel
Date
Departure
Destination
Today
14:10
Today
14:35
MULTIDRUG-RESISTANT
MICROORGANISMS
Wasowu
MULTIDRUG-RESISTANT
MICROORGANISMS
Salhet
Today
14:40
Today
14:45
MULTIDRUG-RESISTANT
MICROORGANISMS
Morador
MULTIDRUG-RESISTANT
MICROORGANISMS
Korobondo
Today
14:55
Baxjö
Today
15:00
Holmen
Today
15:00
Today
15:00
MULTIDRUG-RESISTANT
MICROORGANISMS
Fuja
MULTIDRUG-RESISTANT
MICROORGANISMS
Chanbun
Today
15:05
Today
15:05
MULTIDRUG-RESISTANT
MICROORGANISMS
Tólos
MULTIDRUG-RESISTANT
MICROORGANISMS
Pasu Rial
Today
15:10
Wasserdam
Today
15:15
Today
15:15
MULTIDRUG-RESISTANT
MICROORGANISMS
Bolasir
Mørup
©Istockphoto
In short…we have a problem !
• Growing rates of resistance
• Inappropriate use of
antibiotics
• Decreasing pipeline of new
antibiotics
15. Turnidge J et al. MJA 2009: 191(7): 368-373
Modern Medicine at Risk
• Loss of effective antibiotic treatment
could make routine infections deadly Cancer Treatment
- Pneumonia
• >600,000 patients
will receive
- Urinary tract infections
chemotherapy in
- Wound infections
20141
• Patients who receive specialized care • ~60,000 cancer
patients will be
will be at highest risk
hospitalized with
- Cancer chemotherapy
neutropenia and
infections2
- Complex surgery
• 1 in 14 of these will
- Joint replacements
die from this
- Organ transplants
complication2
Kantar Health, Cancer Impact
- Sepsis
Caggiano et al, 2005, Cancer
- Dialysis
1
2
Antimicrobial resistance
A threat to patient safety
Limitedoptions
optionsforfor
Limited
treatment
treatment
Each year, in the EU/EAA:
2.5 million attributable
extra hospital days
Increased length Increased
of
length25,000
of
attributable deaths
hospital stays hospital stays
Increased patient
morbidity and mortality
Increased patient
NOTE: Based and
on only
5 MDR bacteria
morbidity
mortality
and 4 types of infection
Source: ECDC, 2009.
In: http://ecdc.europa.eu/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdf
AR Requires Global Action
Complex Problem
Lin V. (2016). AMR and UHC. Bi-regional Technical Consultation on AMR in
36
Asia. WHO WPRO. 14-15 April, Tokyo, Japan.
Humans + Animals = One Health
Prudent use of antibiotics:
Everyone is responsible!
Action 5. Regulate antibiotic distribution in humans & food
animals & agriculture & industry
• Agriculture
Antibiotic Injection
H
• Industry
 Ethanol production from sugarcane
Antibiotic Spray
Antibiotic use for growth promotion and
disease prevention
2/3rds of the tonnage of antibiotics sold
worldwide are used in agriculture
Thailand AMR Containment and Prevntion Program 2013-2016
• AMR Chain in Community in Thailand
Thailand AMR Containment and Prevention Program 2013-2016
• AMR Chain in Hospital in Thailand
Infection Prevention & Control (IPC)
Thailand AMR Containment and Prevention Program 2013-2016
AMR chain in community
AMR chain in hospital
IPC
AMR affects all citizens
• No matter who you are, you are at risk of being colonized and/or
infected with AMR bacteria
• AMR matters everybody
Antimicrobial Resistance
68th World Health Assembly
May, 2015
Tackling antimicrobial drug
resistance
Delegates at the World Health
Assembly endorsed a global action
plan to tackle antimicrobial resistance
- including antibiotic resistance, the
most urgent drug resistance trend.
Antimicrobial resistance is occurring
everywhere in the world,
compromising our ability to treat
infectious diseases, as well as
undermining many other advances in
health and medicine.
WHO Global Action Plan
Antimicrobial Resistance
The plan sets out 5 objectives:
1.
2.
3.
4.
5.
Improve awareness and
understanding of antimicrobial
resistance;
Strengthen surveillance and
research;
Reduce the incidence of infection;
Optimize the use of antimicrobial
medicines;
Ensure sustainable investment in
countering antimicrobial
resistance.
Step-by-step approach for
development and implementation
of hospital antibiotic policy and
standard treatment guidelines
Five strategic objectives
1. Improve awareness and understanding
2. Strengthen knowledge through surveillance &
research
3. Reduce incidence of infection
4. Optimize use of antimicrobial medicines
5. Ensure sustainable investment
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| February 2016
AR Requires Global Action
Improve Laboratory
Capacity
Expand Infection
Control Programs
Develop National
Tracking Programs
Implement Antibiotic
Stewardship
Programs
Thailand AMR Containment and Prevention Program 2013-2016
AMR Core Campaign
Slogan : Stopping AMR is Everybody’s Business
Make better use of existing antibiotics
Image Courtesy of Shutterstock
Bacterial diseases are still major killers in develo
countries because of lack of access to antibio
O’Brien et al, Lancet 2009
Global Health Security Agenda
Prevent avoidable
catastrophes
Detect threats early
Respond rapidly
and effectively
Action Packages to Achieve Targets
Antimicrobial Resistance
National Laboratory Systems
Zoonotic Diseases
Surveillance
Emergency Operations
Centers
Linking Public Health
with Law Enforcement
and Multisectoral Rapid
Response
Biosafety/Biosecurity
Immunization
Reporting
Workforce Development
Medical
Countermeasures and
Personnel Deployment
Building resilient health system to contain AMR - UHC
UHC
‘One Health’ – a multisectoral approach to AMR
UHC
‘One Health’
Containment of AMR as a Development Agenda
UHC
‘One Health’
SDGs
National, Regional and Global actions to contain AMR
UHC
‘One Health’
SDGs
GOVERNANCE OF AMR as a development agenda
National, Regional and Global actions to contain AMR
UHC
‘One Health’
SDGs
GOVERNANCE OF AMR as a development agenda
National
Regional
Global
National Action Plan
on AMR
Harmonization of
surveillance and
regulations
Enhance R&D
(new antibiotics and
diagnostics)
Antimicrobial Resistance
A Threat to Sustainable Development
Transforming our world: the 2030 Agenda for Sustainable Development
‘We will equally accelerate the pace of progress made in fighting malaria, HIV/AIDS, tuberculosis, hepatitis,
Ebola and other communicable diseases and epidemics, including by addressing growing antimicrobial
resistance and the problem of unattended diseases affecting developing countries’
Transforming our world: the 2030 Agenda for Sustainable Development
Antimicrobial Resistance
Antimicrobial Resistance
Antimicrobial Resistance
Antimicrobial Resistance
Awareness
and
Advocacy
Surveillance is a prerequisite for
Prevention and Control of AMR
Detecting and understanding the problem
Decision making and design
of interventions
Monitoring the effect of interventions and make
corrective actions
20
“Drug resistance follows the
Drug like a faithful shadow.”
- Paul Ehrlich 1854-1915
TERIMAKASIH
Antibiotics are
a precious resource
 Take antibiotics only as prescribed
World Health House
Indraprastha Estate,
Mahatma Gandhi Marg,
New Delhi-110002, India
Email:[email protected]
www.searo.who.int
 Help prevent the emergence of
resistance
Antimicrobial Resistance
SEA-HLM-414